Transcript Emergency Department Splinting Techniques

Splinting Workshop
Broward General Medical Center
Introduction
• Evidence of rudimentary splints found as early as 500 BC.
• Good evidence that Moses was wearing double sugar-tong
when parting Red Sea.
• Used to temporarily immobilize fractures, dislocations,
and soft tissue injuries.
• Circumferential casts abandoned in the ED - increased
compartment syndrome and other complications, splints
easier to apply, splints ideal for the ED - maximum
swelling.
Indications for Splinting
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Fractures
Sprains
Joint infections
Tenosynovitis
Acute arthritis / gout
Lacerations over joints
Puncture wounds and animal bites of
the hands or feet
Splinting Equipment
• Plaster of Paris
– Made from gypsum - calcium sulfate dihydrate
– Exothermic reaction when wet - recrystallizes (can burn
patient)
– Warm water - faster set, but increases risk of burns
– Fast drying - 5 - 8 minutes to set
– Extra fast-drying - 2 - 4 minutes to set - less time to mold
– Can take up to 1 day to cure (reach maximum strength)
– Upper extremities - use 8-10 layers
– Lower extremities - 12-15 layers, up to 20 if big person
(increased risk of burn!)
Splinting Equipment
• Ready Made Splinting Material
– Plaster (OCL)
• 10 -20 sheets of plaster with padding and cloth
cover
– Fiberglass (Orthoglass)
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Cure rapidly (20 minutes)
Less messy
Stronger, lighter, wicks moisture better
Less moldable
Splinting Equipment
• Stockinette
• protects skin, looks nifty
• cut longer than splint
• 2,3,4,8,10,12-in. widths
• Padding - Webril
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2-3 layers, more if anticipate lots of swelling
Extra over elbows, heels
Be generous over bony prominences
Always pad between digits when splinting hands/feet or when
buddy taping
• Avoid wrinkles
• Do not tighten - ischemia!
• Ace wraps
General Principles of Splint Application
Stockinette
applied to
extend abt 2 3 inches
beyond
plaster.
2-3 layers of
Webril are
applied and
smoothed.
Plaster applied
and stockinette
rolled over
plaster edge.
Ace wrap
Plaster molded
applied over as it dries.
plaster.
Specific Splints and Orthoses
Upper Extremity
Lower Extremity
• Elbow/Forearm
• Knee
– Long Arm Posterior
– Double Sugar - Tong
• Forearm/Wrist
– Volar Forearm / Cockup
– Sugar - Tong
• Hand/Fingers
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Ulnar Gutter
Radial Gutter
Thumb Spica
Finger Splints
– Knee Immobilizer / Bledsoe
– Bulky Jones
– Posterior Knee Splint
• Ankle
– Posterior Ankle
– Stirrup
• Foot
– Hard Shoe
Long Arm Posterior Splint
• Indications
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Elbow and forearm injuries:
Distal humerus fx
Both-bone forearm fx
Unstable proximal radius or ulna
fx (sugar-tong better)
• Doesn’t completely eliminate
supination / pronation -either
add an anterior splint or use a
double sugar-tong if complex
or unstable distal forearm fx.
Double Sugar Tong
• Indications
– Elbow and forearm fx prox/mid/distal radius and
ulnar fx.
– Better for most distal forearm
and elbow fx because limits
flex/extension and pronation
/ supination.
10
90
Forearm Volar Splint aka ‘Cockup’ Splint
• Indications
– Soft tissue hand / wrist
injuries - sprain, carpal tunnel
night splints, etc
– Most wrist fx, 2nd -5th
metacarpal fx.
– Most add a dorsal splint for
increased stability - ‘sandwich
splint’ (B).
– Not used for distal radius or
ulnar fx - can still supinate and
pronate.
Forearm Sugar Tong
• Indications
– Distal radius and ulnar
fx.
• Prevents pronation /
supination and
immobilizes elbow.
Hand Splinting
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The correct position for most hand splints
is the position of function, a.k.a. the
neutral position. This is with the the
hand in the “beer can” position (which
may have contributed to the injury in the
first place) : wrist slightly extended (1025°) with fingers flexed as shown.
When immobilizing metacarpal neck
fractures, the MCP joint should be flexed
to 90°.
Have the patient hold an ace wrap (or a
beer can if available) until the splint
hardens.
For thumb fx, immobilize the thumb as if
holding a wine glass.
Radial and Ulnar Gutter
•Indications
•Fractures, phalangeal and
metacarpal, and soft tissue
injuries of the little and ring
fingers.
•Indications
•Fractures, phalangeal and
metacarpal, and soft tissue
injuries of index and long
fingers.
Thumb Spica
• Indications
– Navicular fx - seen or
suspected (check snuffbox
tenderness)
– Lunate fx, lunate or perilunate
disl’n.
– All thumb fx.
– De Quervain tenosynovitis.
• Notching the plaster (shown)
prevents buckling when wrapping
around thumb.
• Wine glass position.
Finger Splints
• Sprains - dynamic
splinting (buddy
taping).
• Dorsal/Volar finger
splints - phalangeal fx,
though gutter splints
probably better for
proximal fxs.
Jones Compression Dressing - aka
Bulky Jones
• Procedure
• Indications
– Short term immobilization
of soft tissue and
ligamentous injuries to the
knee or calf.
• Allows slight flexion and
extension - may add posterior
knee splint to further
immobilize the knee.
– Stockinette and Webril.
– 1-2 layers of thick cotton
padding.
– 6 inch ace wrap.
Posterior Ankle Splint
• Indications
– Distal tibia/fibula fx.
– Reduced dislocations
– Severe sprains
– Tarsal / metatarsal fx
• Use at least 12-15 layers of plaster.
• Adding a coaptation splint (stirrup)
to the posterior splint eliminates
inversion / eversion - especially
useful for unstable fx and sprains.
Stirrup Splint
• Indications
– Similiar to posterior splint.
– Less inversion /eversion and
actually less plantar flexion
compared to posterior
splint.
– Great for ankle sprains.
– 12-15 layers of 4-6 inch
plaster.
Other Orthoses
• Knee Immobilizer
– Semirigid brace, many models
– Fastens with Velcro
– Worn over clothing
• Bledsoe Brace
– Articulated knee brace
– Amount of allowed flexion and extension can be adjusted
– Used for ligamentous knee injuries and post-op
• AirCast/ Airsplint
– Resembles a stirrup splint with air bladders
– Worn inside shoe
• Hard Shoe
– Used for foot fractures or soft tissue injuries
Complications
• Burns
– Thermal injury as plaster dries
– Hot water, Increased number of
layers, extra fast-drying, poor
padding - all increase risk
– If significant pain - remove splint to
cool
• Ischemia
– Reduced risk compared to casting
but still a possibility
– Do not apply Webril and ace wraps
tightly
– Instruct to ice and elevate extremity
– Close follow up if high risk for
swelling, ischemia.
– When in doubt, cut it off and look
– Remember - pulses lost late.
• Pressure sores
– Smooth Webril and plaster well
• Infection
– Clean, debride and dress all
wounds before splint application
– Recheck if significant wound or
increasing pain
Any complaints of
worsening pain Take the splint off
and look!